Health inspection·March 27, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide services which met professional standards for one resident (Resident 1) of three sampled residents when nursing staff did not document physician's orders were carried out. Residents Affected - Few This failure contributed to formation and worsening of Resident 1's sacrococcyx (the backside area between a person ' s hips and down to the tailbone) wound. Findings: A review of Resident 1's admission record indicated an initial admission date of 2/15/23 with diagnoses which included mitral valve insufficiency (a condition in which the valve between two heard chambers does not close tightly, which allows blood to flow backward in the heart) and traumatic hemorrhage of the cerebrum (trauma to the head which results in blood intermixing with brain tissue). A review of Resident 1's Braden Scale (an assessment tool used for predicting pressure injury risk) assessment dated [DATE] at 6:22 p.m. indicated a score of 9 which indicated Resident 1 was at very high risk for developing a pressure injury. A review of Resident 1's history and physical written by a physician dated 2/16/23 at 1:13 p.m. indicated, SNF [Skilled Nursing Facility] admission .Skin- SC [sacroccoccyx] Stage 1 [injury of the skin as a result of continuous pressure characterized by superficial reddening that when pressed does not turn white] redness .Assessment and Plan .Decubitus [laying down area] ulcer: recommendation(s) barrier cream, foam dressing, position changes . A review of a care plan which focused on Resident 1's Stage 1 pressure injury on the coccyx (tailbone), initiated on 2/21/23, indicated nursing staff would, provide proper skin care to assist Resident 1 to reach her goal of preventing further deterioration of skin integrity. A review of Resident 1's Treatment Administration Record (TAR) dated February 2023 indicated staff did not document the physician's order, Barrier cream with foam dressing to redness to coccyx .change every day with diaper change and/or .when soiled .every shift . was carried out on: the day and night shifts of 2/17/23, on the day and evening shifts of 2/19/23, day shift of 2/20/023, and the evening shift of 2/23/23. A review of Resident 1's TAR dated March 2023 indicated the following physician's orders: · Cleanse coccyx area noted with redness with NS [normal saline, a solution used to cleanse Page 1 of 3 055276 055276 03/27/2024 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wounds], pat dry and apply .paste .every shift . was not carried out on: night shift of 3/6/23, day shift of 3/12/23, night shifts of 3/15/23 and 3/16/23, day shift of 3/20/23, evening shift of 3/21/23, and night shifts of 3/23/23 to 3/27/23; · Air mattress every shift was not carried out on: night shift of 3/6/23, day shifts of 3/10/23 and 3/11/23, night shifts of 3/15/23 and 3/16/23, day shift of 3/20/23, evening shift of 3/21/23, and night shifts of 3/24/23 to 3/27/23; and, · Apply barrier cream with every diaper change and PRN [as needed] when soiled .every shift for peri-care . was not carried out on: night shift of 3/6/23, day shift of 3/12/23, night shifts of 3/15/23 and 3/16/23, day shift of 3/20/23, evening shift of 3/21/23, and night shifts of 3/24/23 to 3/27/23. A review of Resident 1's TAR dated April 2023 indicated the following physician's orders: · Cleanse coccyx area noted with redness with NS, pat dry and apply .paste .every shift . was not carried out on: evening shift of 4/15/23, night shift of 4/16/23, evening shift of 4/19/23, evening shift of 4/21/23, day and evening shifts of 4/22/23, day shift of 4/24/23, day shift of 4/26/23, evening shift of 4/28/23, and day shift of 4/29/23; · Air mattress every shift was not carried out on: evening shift of 4/15/23, night shift of 4/16/23, evening shift of 4/19/23, evening shift of 4/21/23, day and evening shifts of 4/22/23, day shift of 4/24/23, day shift of 4/26/23, evening shift of 4/28/23, and day shift of 4/29/23; and, · Apply barrier cream with every diaper change and PRN when soiled .every shift for peri-care . was not carried out on: evening shift of 4/15/23, night shift of 4/16/23, evening shift of 4/19/23, evening shift of 4/21/23, day and evening shifts of 4/22/23, day shift of 4/24/23, day shift of 4/26/23, evening shift of 4/28/23, and day shift of 4/29/23. A review of Resident 1's TAR dated May 2023 indicated the following physician's orders: · Cleanse coccyx area noted with redness with NS, pat dry and apply .paste .every shift . was not carried out on: day shift of 5/3/23, day and evening shifts of 5/6/23, night shift of 5/10/23, day shift of 5/12/23, evening shifts of 5/15/23 and 5/16/23, day shift of 5/17/23, evening shift of 5/18/23, evening shifts of 5/21/23 to 5/23/23, and day shift of 5/24/23; · Air mattress every shift was not carried out on: day shift of 5/3/23, day and evening shifts of 5/6/23, night shift of 5/10/23, day shift of 5/12/23, evening shifts of 5/15/23 and 5/16/23, day shift of 5/17/23, evening shift of 5/18/23, evening shifts of 5/21/23 to 5/23/23, and day shift of 5/24/23; and, · Apply barrier cream with every diaper change and PRN when soiled .every shift for peri-care . was not carried out on: day shift of 5/3/23, day and evening shifts of 5/6/23, night shift of 5/10/23, day shift of 5/12/23, evening shifts of 5/15/23 and 5/16/23, day shift of 5/17/23, evening shift of 5/18/23, evening shifts of 5/21/23 to 5/23/23, and day shift of 5/24/23. A review of Resident 1's TAR dated June 2023 indicated the following physician's orders: · Cleanse coccyx area noted with redness with NS, pat dry and apply .paste .every shift . 055276 Page 2 of 3 055276 03/27/2024 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0658 Level of Harm - Minimal harm or potential for actual harm was not carried out on: evening shift of 6/1/23, day shift of 6/3/23, day shift of 6/5/23, day shift of 6/11/23, day shift of 6/13/23, day shift of 6/16/23, and day shift of 6/19/23; · Air mattress every shift was not carried out on: evening shift of 6/1/23, day shift of 6/3/23, day shift of 6/5/23, day shift of 6/11/23, day shift of 6/13/23, day shift of 6/16/23, and day shift of 6/19/23; and, Residents Affected - Few · Apply barrier cream with every diaper change and PRN when soiled .every shift for peri-care . was not carried out on: evening shift of 6/1/23, day shift of 6/3/23, day shift of 6/5/23, day shift of 6/11/23, day shift of 6/13/23, day shift of 6/16/23, and day shift of 6/19/23. A review of a SNF rounding note written by a physician dated 6/20/23 at 9:50 a.m. indicated, .Patient noted to have blisters and open area on the back, noted by staff over the weekend .Assessment and Plan .Pressure [Injury] of buttock Stage 2 (partial thickness skin loss), unspecified side has blisters and open area, DTI [Deep Tissue Injury, a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure] most likely with stage 2 on the open area .Has blister filled with fluid .Will apply [foam dressing] for now, continue to monitor, Patient already on airflow mattress . A review of Resident 1's wound evaluation dated 7/21/23 at 3:33 p.m. indicated, Body Location .Sacrum .Pressure [ulcer]- Unstageable (slough and/or eschar) .Area .+133% .Length .+24% .Width .+37% .Deepest Point .+100% .Longest Tunnel .+100% .Negative percentage values indicate wound is getting smaller .[Resident] sacrum area has opened up with an unstageable wound . A review of Resident 1's wound evaluation dated 7/27/23 at 10:32 a.m. indicated, Body Location .Sacrum .Pressure [ulcer]- Stage 4 .[Resident] has open wound on sacrum stage 4 . In a concurrent interview and record review on 5/17/24 at 10:49 a.m. with the Director of Nursing (DON), Resident 1 ' s TARs dated February 2023 through June 2023 were reviewed. The TARs indicated innumerable dates with no licensed staff initials in the boxes to demonstrate wound treatment orders were administered. The DON confirmed and stated, .If you did not document, it did not happen .[It was] the LN ' s responsibility to ensure orders are carried out .Yes, LN should document .according to TAR ' s chart codes . The DON acknowledged it was a deficiency. A review of the facility ' s policy and procedure titled Medication and Treatment Orders, revised July 2016, indicated, Orders for . treatments . shall be administered . upon the written order of a person duly licensed and authorized to prescribe . A review of the facility ' s policy and procedure titled, Prevention of Pressure Injuries, revised April 2020, indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable . Prevention .Keep the skin clean and hydrated . Clean promptly after episodes of incontinence .Use a barrier product to protect skin from moisture .Select appropriate support surfaces based the resident's risk factors . 055276 Page 3 of 3